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A 49-year-old man is referred for evaluation of a left groin mass found during a routine screening physical. He has well-controlled hypertension but no other chronic disease or history of prior surgery. He is 70 in (178 cm) tall and weighs 160 lb (73 kg). On physical examination, blood pressure is 132/80 mm Hg, pulse is 75/min, and respirations are 16/min and unlabored. With the patient in supine position, the abdomen is soft and nontender; there is no organomegaly, and no masses are palpated. No groin or scrotal masses are appreciated, and there is no tenderness to palpation.
Which of the following is the most appropriate next step in management?

a. Reassure the patient that no hernia is present
b. Order computed tomography of the pelvis
c. Have the patient stand up and perform the Valsalva maneuver
d. Advise the patient to return to clinic when the mass is protruding
e. Obtain an ultrasound of the groin

c. Have the patient stand up and perform the Valsalva maneuver

A 49-year-old man is referred for evaluation of a left groin mass found during a routine screening physical. He has well-controlled hypertension but no other chronic disease or history of prior surgery. He is 70 in (178 cm) tall and weighs 160 lb (73 kg). On physical examination, blood pressure is 132/80 mm Hg, pulse is 75/min, and respirations are 16/min and unlabored. With the patient in supine position, the abdomen is soft and nontender; there is no organomegaly, and no masses are palpated. No groin or scrotal masses are appreciated, and there is no tenderness to palpation.

Which of the following differentials should be given greatest consideration when choosing the next step in management?

a. Epididymitis
b. Testicular torsion
c. Indirect or direct inguinal hernia
d. Direct inguinal hernia but not indirect
e. Indirect inguinal hernia but not direct

c. Indirect or direct inguinal hernia

During a routine follow-up appointment for well-controlled dyslipidemia, a 26-year-old man is evaluated for a lump in his right groin. He first noted the lump one evening approximately 2 months ago after he helped his fiancé move into a new apartment. The lump was moderately uncomfortable, with pain concentrated in the groin and upper, inner aspect of his right thigh. The mass and discomfort subsided by the next morning, but he has had recurrence of mild to moderate pain during the week, but he is generally asymptomatic in the morning before going to work at his job at a factory where he stands most of the day. He has no prior surgical history, and his medical history is otherwise unremarkable. On physical examination, a soft, reducible mass consistent with a hernia is palpated in the right groin; the left groin appears normal. Which of the following is the most likely diagnosis?

a. Direct inguinal hernia
b. Hydrocele
c. Femoral hernia
d. Indirect inguinal hernia
e. Obturator hernia

d. Indirect inguinal hernia

uring a routine follow-up appointment for well-controlled dyslipidemia, a 26-year-old man is evaluated for a lump in his right groin. He first noted the lump one evening approximately 2 months ago after he helped his fiancé move into a new apartment. The lump was moderately uncomfortable, with pain concentrated in the groin and upper, inner aspect of his right thigh. The mass and discomfort subsided by the next morning, but he has had recurrence of mild to moderate pain during the week, but he is generally asymptomatic in the morning before going to work at his job at a factory where he stands most of the day. He has no prior surgical history, and his medical history is otherwise unremarkable. On physical examination, a soft, reducible mass consistent with a hernia is palpated in the right groin; the left groin appears normal. Which of the following is the most appropriate next step in management?

a. Use of a truss to compress the hernia and keep it from protruding
b. Urgent inguinal hernia repair because of a high risk for incarceration
c. Ultrasound examination of the groin to confirm the presence of a hernia
d. Elective open inguinal hernia repair at the patient's convenience
e. Watchful waiting because his symptoms consistently resolve with rest

Elective open inguinal hernia repair at the patient's convenience

During a routine follow-up appointment for well-controlled dyslipidemia, a 26-year-old man is evaluated for a lump in his right groin. He first noted the lump one evening approximately 2 months ago after he helped his fiancé move into a new apartment. The lump was moderately uncomfortable, with pain concentrated in the groin and upper, inner aspect of his right thigh. The mass and discomfort subsided by the next morning, but he has had recurrence of mild to moderate pain during the week, but he is generally asymptomatic in the morning before going to work at his job at a factory where he stands most of the day. He has no prior surgical history, and his medical history is otherwise unremarkable. On physical examination, a soft, reducible mass consistent with a hernia is palpated in the right groin; the left groin appears normal. Which of the following is the most likely source of this patient's pain?

a. Stretching of the genital branch of the genitofemoral nerve
b. Rupture of the transversalis fascia
c. Chronic incarceration of the hernia
d. Compression of the ilioinginal nerve by the hernia
e. Ischemia of the hernia contents

Compression of the ilioinginal nerve by the hernia

During a routine physical examination for a new job, a 50-year-old man is found to have a small inguinal hernia in the right groin. He didn't know he had it. He is asymptomatic, and his medical history is otherwise unremarkable. His father had successful hernia repair surgery at the age of 52 years. Which of the following is the most appropriate treatment recommendation?

a. Close follow-up of the patient every 6 months for at least 5 years
b. Diagnostic laparoscopy to confirm the diagnosis with plans to repair it if the defect is greater than 1.5 cm
c. Elective laparoscopic inguinal hernia repair at a convenient time
d. Elective open inguinal hernia repair at a convenient time
e. Reassurance of the patient with instructions to return if symptoms develop

Reassurance of the patient with instructions to return if symptoms develop

A 73-year-old man presents with signs and symptoms of a new, mildly symptomatic right inguinal hernia. When conducting the review of system while obtaining the patient's medical history, which of the following lines of questioning is LEAST likely to be relevant?

a. Pulmonary symptoms, such as chronic cough
b. Urinary symptoms, particularly benign prostatic hypertrophy
c. Hematologic symptoms, including poor clotting
d. Endocrine symptoms, particularly hypothyroidism
e. Gastrointestinal symptoms, including chronic constipation

Endocrine symptoms, particularly hypothyroidism

A 73-year-old man presents with signs and symptoms of a new, mildly symptomatic right inguinal hernia. During elective open anterior repair of the hernia, the external oblique aponeurosis is opened in the direction of its fibers. Which of the following can the surgeon expect to find beneath the external oblique?

a. Superficial inguinal ring
b. Internal oblique aponeurosis
c. Lacunar ligament
d. Femoral canal
e. Spermatic cord

Spermatic cord

A 30-year-old woman is evaluated for avone-day history of obstipation and severe nausea with increasingly bilious emesis. She has no history of previous abdominal surgery. On physical examination, the abdomen is distended and diffusely tympanitic but without peritoneal signs. A firm right groin mass is palpated and does not reduce in the supine position or with manual manipulation. Which of the following is the most likely diagnosis?

a. Pantaloon hernia
b. Hyperemesis gravidarum
c. "Sports hernia"
d. Incarcerated hernia
e. Richter's hernia

Incarcerated hernia

When the contents of a hernia sac cannot be returned to their normal anatomic location, the hernia is said to be incarcerated.

A 30-year-old woman is evaluated for a one-day history of obstipation and severe nausea with increasingly bilious emesis. She has no history of previous abdominal surgery. On physical examination, the abdomen is distended and diffusely tympanitic but without peritoneal signs. A firm right groin mass is palpated and does not reduce in the supine position or with manual manipulation. Upon exploration of the inguinal canal, no hernia is found in the indirect or direct spaces. Which of the following the most appropriate strategy to determine if a femoral hernia is present?

a. Divide the transversalis fascia to expose the femoral canal
b. Identify the processus vaginalis and follow it to the deep inguinal ring
c. Divide the round ligament to expose the femoral vessels
d. Open the peritoneum to explore the femoral canal
e. Obtain an intra-operative ultrasound to look for a femoral hernia

Divide the transversalis fascia to expose the femoral canal

A 30-year-old woman is evaluated for a one-day history of obstipation and severe nausea with increasingly bilious emesis. She has no history of previous abdominal surgery. On physical examination, the abdomen is distended and diffusely tympanitic but without peritoneal signs. A firm right groin mass is palpated and does not reduce in the supine position or with manual manipulation. The patient is scheduled to undergo mesh repair of a femoral hernia. During the procedure, the mesh must be anchored to which of the following anatomic structures?

a. The ileopubic tract (conjoined tendon)
b. The iliac crest
c. The shelving edge of the inguinal ligament
d. The deep inguinal ring
e. The pectineal (Cooper's) ligament

The pectineal (Cooper's) ligament

A 21-year-old male college basketball player undergoing evaluation for groin pain is found to have bilateral reducible inguinal hernias. Which of the following is the most appropriate management?

a. Physical therapy
b. Laparoscopic hernia repair
c. Elective open inguinal hernia repair with mesh
d. High ligation of the sac
e. Watchful waiting

Laparoscopic hernia repair

A male infant who was born at 32 weeks gestation is found to have bilateral reducible inguinal hernias. Which of the following is the most appropriate next step in management?

a. Laparoscopic hernia repair
b. Physical therapy
c. Elective open inguinal hernia repair with mesh
d. Watchful waiting
e. High ligation of the sac

High ligation of the sac

Mesh is never used.

A 2-year-old boy is evaluated for a right groin mass that his mother first noticed during a diaper change 3 weeks ago. The child had an upper respiratory infection at the time, and he had a bad coughing episode a few minutes before her discovery. The respiratory infection has since resolved, but the mass persists. His mother reports that the mass disappears when she pushes it with her fingers, but it has been less mobile during the past 2 days. The child is otherwise healthy and takes no medications.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 84/min and regular, and respirations are 22/min. Examination shows a reducable mass in the right groin above the inguinal ligament. The remainder of the examination is unremarkable.

Which of the following is the most likely diagnosis?

a. Femoral hernia
b. Retractile testis
c. Indirect hernia
d. Noncommunicating hydrocoele
e. Direct hernia

Indirect hernia

An 8-month-old boy is brought to the pediatrician after his parents noted swelling on the right side of the child's groin. The area is not sensitive to touch, but the swelling seems to be intermittent. The child is otherwise healthy and takes no medications.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 96/min and regular, and respirations are 26/min. Palpation of the inguinal area elicits the silk glove sign.

Which of the following is the most likely explanation for this clinical finding?

a. Non-communicating hydrocoele
b. Retractile testis
c. Patent processus vaginalis
d. Absent vas deferens
e. Absence of a hernia sac

Patent processus vaginalis

A 5-month-old boy is brought to the pediatrician for evaluation of a small mass on the left side of the infant's groin. Her son had previously been in good health until he developed a severe cough 4 days ago. A diagnosis of croup was made, and he has been responding well to albuterol treatments. The patient's mother reports that she first felt the mass when changing his diaper after a particularly bad coughing episode.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 110/min and regular, and respirations are 34/min. On palpation of the groin and inguinal area, no mass is palpable.

Which of the following is the best strategy to establish a diagnosis?

a. Place the tip of the examining finger in the inguinal canal and palpate at the external ring as the infant coughs
b. Palpate the groin while the child is comfortable in the parent's lap
c. Palpate the external ring during a prolonged deep breath
d. Observe for 10 minutes
e. Elicit crying by holding both of the child's legs so he cannot move them

Elicit crying by holding both of the child's legs so he cannot move them

A 3-year-old girl is evaluated for a lump in the groin that her mother discovered this morning while bathing her. She says the lump does not seem to be painful to the child, who has been eating and playing normally since bathtime. The patient is otherwise healthy and receives no medications.

The patient is playful but apprehensive to examination. Vital signs are normal. Examination of the groin shows a mobile, nontender, 1 × 1-cm mass in the right groin. No redness or swelling of the skin is noted over the mass. The external genitalia and abdomen are otherwise normal.

The patient's mass is most likely which of the following?
a. Ovary
b. Germ cell tumor
c. Dermoid cyst
d. Lymph node
e. Testicle

ovary

A 3-year-old girl is evaluated for a lump in the groin that her mother discovered this morning while bathing her. She says the lump does not seem to be painful to the child, who has been eating and playing normally since bathtime. The patient is otherwise healthy and receives no medications.

The patient is playful but apprehensive to examination. Vital signs are normal. Examination of the groin shows a mobile, nontender, 1 × 1-cm mass in the right groin. No redness or swelling of the skin is noted over the mass. The external genitalia and abdomen are otherwise normal.

Which of the following is the best next step in management?

a. Reassurance that the mass is benign and will likely disappear on its own
b. Elective herniorrhaphy, instructing mother to remain alert for signs of strangulation
c. Emergent herniorrhaphy
d. Forcible reduction of the herniated mass before it becomes incarcerated
e. Biopsy of the mass

Elective herniorrhaphy, instructing mother to remain alert for signs of strangulation

An 8-month-old boy is brought to the pediatrician after his parents noted intermittent swelling on the right side of the child's groin. The area is not sensitive to touch. The child is otherwise healthy and takes no medications.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 88/min and regular, and respirations are 24/min. Palpation of the inguinal area elicits the silk glove sign.

Which of the following is the most appropriate surgical approach to manage this patient's condition?

a. Approximation of the transversalis fascia to the external oblique aponeurosis
b. High ligation of the hernia sac at the level of the internal ring*
c. Laparoscopic closure of the external ring
d. Sutured mesh over the internal ring
e. Approximation of the transversalis fascia to the inguinal ligament

High ligation of the hernia sac at the level of the internal ring*

A 4-month-old boy is brought to the physician for follow-up evaluation 2 weeks after undergoing surgical repair of an indirect inguinal hernia. The procedure, simple dissection and high ligation with removal of the hernia sac, was uncomplicated, and his postoperative course has been uneventful.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 108/min and regular, and respirations are 36/min. Examination of the inguinal area shows a well-healing surgical scar and no swelling.

Which of the following is the most appropriate estimated lifetime risk of hernia recurrence for this patient?

5%
<1%
14%
10%
8%

<1%

A now 5-week-old term infant male presents to the emergency room with post-prandial projectile non-bilious and non-bloody emesis for two weeks. The mother states that the baby has only been having two or three wet diapers per day over the past week (previously had 6-8 wet diapers per day). On review of the vitals, temperature is 37.4 C, heart rate is 124, blood pressure is 69/36, respirations are 34/min, oxygen saturation is 100% on room air. On exam, the patient is alert with a flat fontanel and normal skin turgor with capillary refill of 2 seconds. He has a palpable "olive" in the epigastrium. Ultrasound demonstrates a thickened and elongated pylorus.

Which of the following best describes this patient's metabolic status

a. Hypokalemic, hypochloremic metabolic alkalosis with acuduria
b. Normal electrolytes and urinalysis
c. Hyperkalemic, hyperchloremic metabolic alkalosis with acuduria
d. Hypokalemic, hypochloremic metabolic alkalosis with alkaline urine
e. Hypokalemic, hypochloremic metabolic acidosis with aciduria

Hypokalemic, hypochloremic metabolic alkalosis with aciduria

hypovolemia from ongoing volume losses leads to renal retention of sodium at all costs, including exchanging sodium ions for potassium and hydrogen ions, despite ongoing hypokalemia and alkalosis, which leads to "paradoxic aciduria."

A 3-week-old 4 kg male infant presents with persistent emesis after feeding. The parents report that the color of the emesis is consistent with breast milk. They additionally report their concern as he has not been as active as usual, and recently they have not noticed any wet diapers. Laboratory studies demonstrate sodium of 135, chloride of 90, potassium of 3.0 and HCO of 34. Ultrasound reveals a pyloric channel length of 20 mm, with a muscle wall thickness of 4 mm and no flow of through the pyloric channel. Following appropriate resuscitation and correction of electrolyte imbalances, you take the patient to the operating room for a laparoscopic pyloromyotomy. In this operation:

a. The pyloric muscle is incised until the submucosa is exposed
b. The pyloric muscle is incised until the outer longitudinal smooth muscle is exposed
c. The pyloric muscle is incised until the muscularis externa is exposed
d. The pyloric muscle is incised until the mucosa is exposed
e. The pyloric muscle is incised until the inner circular smooth muscle is exposed

The pyloric muscle is incised until the submucosa is exposed

A 6-week-old male infant is brought to the emergency department with a 3-week history of postprandial projectile emesis that has increased in frequency and intensity. The infant was delivered at 37 weeks' gestation following an otherwise uncomplicated pregnancy. Over the past 2 weeks, the primary pediatrician has advised the parents to try small feedings of several formula varieties, including lactose-free and soy formulations, but the patient's symptoms did not respond. Physical examination demonstrates diminished skin turgor and a palpable "olive" in the epigastrium. Results of a basic metabolic panel show serum sodium of 135 mEq/L, serum potassium of 3.5 mEq/L, serum chloride of 82 mEq/L, and serum bicarbonate 38 mEq/L; blood urea nitrogen of 20 mg/dL, serum creatinine of 0.8 mg/dL, and plasma glucose of 86 mg/dL. Ultrasound examination reveals a thickened, elongated pylorus.

Which of the following most likely characterizes the color of the patient's emesis?

a. Formula-colored
b. Feculent
c. Purulent
d. Blood-tinged or frankly bloody
e. Bilious

Formula-colored

A previously healthy full-term female infant, now 4 weeks old, is brought to her primary pediatrician because of a 3-day history of postprandial projectile vomiting of nonbilious emesis. She had previously been taking 3 ounces of milk-based formula feeds every 3 hours without difficulty and had been gaining weight on previous well-child examinations. She typically has 6 wet diapers and 3 bowel movements daily; she has not had fever or rash.

On physical examination, the patient is 9.6 lb (4.35 kg); at her last appointment 2 weeks ago, she was was 9.4 lb (4.25 kg). Her temperature is 98.8°F (37.1°C), pulse is 115/min and regular, respirations are 26/min, and blood pressure is 62/38 mm Hg. Oxygen saturation is 100% on room air. The fontanel is full, skin turgor is good, and mucous membranes are moist. The extremities are warm and well perfused, and capillary refill is brisk. No heart murmur is heard. The lungs are clear to auscultation. Abdominal examination discloses no distention, and a palpable "olive" is noted in the epigastrium. There are no hernias or masses.

Further questioning of the parents will most likely elicit which of the following descriptions of the infant's behavior after each episode of emesis?

a. Seizure
b. Irritable, arching, and in pain
c. Sleepy
d. Irritable, crying, and hungry
e. Alert and comfortable

Irritable, crying, and hungry

A 9-week-old female infant is brought to the emergency department because of postprandial projectile vomiting. Her mother reports the patient has not had a bowel movement for 2 days and has had only one wet diaper during the past 24 hours. The emesis has been nonbilious and nonbloody. The infant was delivered at 37 weeks' gestation following an otherwise uncomplicated pregnancy.

On physical examination, the patient weighs 7.3 lb (3.3 kg); she weighed 7.9 lb (3.6 kg) at birth. Her temperature is 99.0°F (37.2°C), pulse is 144/min, respirations are 48/min, blood pressure is 60/34 mm Hg, and oxygen saturation is 100% on room air. The patient is somnolent and has a sunken fontanel. Skin turgor is diminished, and capillary refill is delayed. An "olive" is palpated in the epigastrium. Results of a basic metabolic panel show serum sodium of 118 mEq/L, serum potassium of 2.8 mEq/L, serum chloride of 59 mEq/L, and serum bicarbonate 49 mEq/L; blood urea nitrogen of 30 mg/dL, serum creatinine of 1.2 mg/dL, and plasma glucose of 56 mg/dL. Upper gastrointestinal examination reveals a narrow, elongated pyloric channel consistent with a "string sign."

When did this patent's symptoms likely begin?

4 hours ago
8 weeks ago
At birth
4 weeks ago
3 days ago

4 weeks ago

A persistently hungry 3-week-old male infant is brought to the emergency department after she felt an abdominal mass while changing his diaper. For the past 48 hours, he has had several episodes of vomiting and has been crying inconsolably. His hunger is worse immediately after vomiting.

On physical examination, his temperature is 99.3°F (37.4°C), pulse is 156/min, respirations are 40/min, and blood pressure 60/40 mm Hg.

Visible peristaltic waves are most likely to be seen in the which of the following locations?

Right upper quadrant
Left upper quadrant
Epigastrium
Left lower quadrant
Right lower quadrant

Right upper quadrant

Clinical examination for hypertrophic pyloric stenosis usually reveals visible peristalsis in the right upper quadrant with palpation of an olive shaped mass in the epigastrium.

A 6-week-old male infant is brought to the pediatrician because of a 1-week history of worsening nonbilious vomiting and inability to tolerate feedings. His parents report that he also seems more sleepy than usual. He has had only 3 wet diapers during the past 24 hours. Physical examination shows a 0.9-lb (0.5-kg) weight loss since his last visit. The patient appears very lethargic but is afebrile. Pulse is 170/min. The fontanelle is sunken, and the abdomen is mildly distended but not tender to palpation. Results of laboratory studies show hypokalemia and hypochloremia.

Which of the following is the most likely underlying pathophysiology of the potassium abnormality

a. Shift of potassium outside the cells due to the metabolic acidosis
b. Reabsorption of potassium and sodium in the kidneys
c. Absorption of hydrogen ions by kidneys in exchange for potassium
d. Shift of potassium into the cells due to metabolic alkalosis
e. Loss of potassium due to excessive gastric losses

Absorption of hydrogen ions by kidneys in exchange for potassium

"Paradoxical aciduria" -

A 6-week-old male infant is brought to the pediatrician because of a three-day history of increasingly severe projectile vomiting. His mother reports that he seems insatiably hungry but is unable to keep down any of his feedings. He has had only one wet diaper during the past 24 hours.

On physical examination, the infant appears mildly dehydrated but is crying. He is afebrile. Pulse rate is 180 beats/min. Examination of the abdomen is unremarkable.

Which of the following diagnostic studies is the most appropriate next step step?

a. Computed tomography of the abdomen
b. Barium swallow
c. Water-soluble upper gastrointestinal series
d. Ultrasound of the abdomen
e. Abdominal x-ray

Ultrasound is the modern gold standard imaging study for the diagnosis of pyloric stenosis.

A 6-week-old female infant is brought the pediatrician because of a 6-day history of vomiting after almost every bottle. During the past 2 days, she has become increasingly lethargic. Trials of soy and elemental formulas have not helped to alleviate the vomiting.

On physical examination, the patient appears listless. The mucous membranes are tacky. Abdominal examination reveals a visible peristaltic wave in the upper quadrants.

An abdominal ultrasound is ordered. Which of the following pyloric measurements would confirm pyloric stenosis as the most likely diagnosis?

a. Pyloric channel 18 mm, thickness 5 mm
b. Pyloric channel 13 mm, thickness 3 mm
c. Pyloric channel 10 mm, thickness 5 mm
d. Pyloric channel 10 mm, thickness 3 mm
e. Pyloric channel 16 mm, thickness 2 mm

Pyloric channel 18 mm, thickness 5 mm

A positive ultrasound for pyloric stenosis shows a pyloric channel greater than or equal to 14 mm and a muscle thickness of greater than or equal to 4 mm

After ordering an ultrasound for 6-week-old male infant with suspected pyloric stenosis, you learn the ultrasound technician who performs pediatric studies is not available until later in the day. A radiologist offers to perform an upper gastrointestinal series to assist you with making a diagnosis.

Which of the following findings on an upper gastrointestinal series would most likely confirm a diagnosis of pyloric stenosis?

a. Air under the diaphragm
b. Spasm of the pyloric channel
c. String sign with shouldering of the pylorus
d. Delayed gastric emptying
e. Double bubble sign

String sign with shouldering of the pylorus

A 3-week-old male infant is brought to the emergency department because of a one-week history of increasing lethargy and persistent vomiting after feeding. The parents report that the color of the emesis is consistent with breast milk. The infant has not had any wet diapers during the past 8 hours.

The infant weighs 8.8 lb (4 kg) and is afebrile. Physical examination shows a sunken fontanelle and dry mucous membranes, but is otherwise unremarkable. Results of laboratory studies shows a serum sodium level of 135 mEq/L, chloride of 90 mEq/L, potassium of 3.0 mEq/L, and bicarbonate of 34 mEq/L. An abdominal ultrasound is performed, demonstrating a pyloric channel length of 20 mm with a muscle wall thickness of 4 mm; no flow through the pyloric channel is apparent.

Which of the following is the most appropriate next step in management?
a. Bolus administration of normal saline, 20 mL/kg
b. Bolus administration of half-normal saline, 10 mL/kg plus 40 mEq potassium chloride
c. Emergent pyloromyotomy
d. Upper gastrointestinal series
e. Administration of dextrose in half-normal saline plus 20 mEq potassium chloride, 16 mL/hr

Bolus administration of normal saline, 20 mL/kg

A 3-week-old male infant is brought to the emergency department because of a one-week history of increasing lethargy and persistent vomiting after feeding. The parents report that the color of the emesis is consistent with breast milk. The infant has not had any wet diapers during the past 8 hours.

The infant weighs 8.8 lb (4 kg) and is afebrile. Physical examination shows a sunken fontanelle and dry mucous membranes, but is otherwise unremarkable. Results of laboratory studies shows a serum sodium level of 135 mEq/L, chloride of 90 mEq/L, potassium of 3.0 mEq/L, and bicarbonate of 34 mEq/L. An abdominal ultrasound is performed, demonstrating a pyloric channel length of 20 mm with a muscle wall thickness of 4 mm; no flow through the pyloric channel is apparent.

Laparoscopic pyloromyotomy is ordered following appropriate resuscitation and correction of electrolyte imbalances. The pyloromyotomy is adequate when which of the following is achieved?

a. The muscularis and submucosa are divided, exposing the mucosa
b. The exposed muscle remains thick distally and is thinned proximally
c. The exposed muscle is thinned distally and remains thick proximally
d. The submucosa is exposed, and the upper and lower half of the exposed pyloric muscle move eccentrically with manipulation.
e. The pyloric muscle is incised until submucosa is exposed

The submucosa is exposed, and the upper and lower half of the exposed pyloric muscle move eccentrically with manipulation.

A 3-week-old male infant is brought to the emergency department because of a one-week history of increasing lethargy and persistent vomiting after feeding. The parents report that the color of the emesis is consistent with breast milk. The infant has not had any wet diapers during the past 8 hours. The infant weighs 8.8 lb (4 kg) and is afebrile. Physical examination shows a sunken fontanelle and dry mucous membranes, but is otherwise unremarkable. Results of laboratory studies shows a serum sodium level of 135 mEq/L, chloride of 90 mEq/L, potassium of 3.0 mEq/L, and bicarbonate of 34 mEq/L. An abdominal ultrasound is performed, demonstrating a pyloric channel length of 20 mm with a muscle wall thickness of 4 mm; no flow through the pyloric channel is apparent.

Following appropriate resuscitation and correction of electrolyte imbalances, laparoscopic pyloromyotomy is performed. After surgery, the infant has small amounts of nonbilious regurgitation while breastfeeding. The mother reports the emesis is not forceful as it had been before the operation. On follow-up examination, the infant does not appear to be any distress. The abdomen is soft and not distended; there is no tenderness to palpation.

Which of the following is the most appropriate next step in management?

a. Immediate initiation of antibiotics
b. Emergent surgery to determine whether any mucosal injury has taken place
c. Change of patient's feeding status to NPO for the next 48 hours
d. Reassurance that the vomiting will resolve with time
e. Upper gastrointestinal series

Reassurance that the vomiting will resolve with time

Pathophysiology of appendicitis

A. Obstruction of the lumen by lymphoid hyperplasia or fecalith
B. Continued mucous production with distention of the appendix
C. Venous obstruction
D. Arterial obstruction
E. Ischemia
F. Gangrene
G. Perforation

A 38 year old man developed severe, right lower quadrant abdominal pain 6 hours prior to his emergency department presentation. Prior to this, he was feeling well.
He has poor appetite, nausea, vomiting, diarrhea, and reports a subjective fever at home, though he did not check his temperature.
He denies dysuria, melena, hematochezia, or a history of similar symptoms. Yesterday, he reports he felt perfectly well.
He has no significant past medical, surgical or family history. He takes no medications or supplements daily and has no known drug allergies.

On physical examination, which of the following would most support your clinical diagnosis:

a. Feeling Hungry
b. Right upper quadrant tenderness, worse with inspiration
c. Observing that the patient lies with his legs extended and resists flexion
d. Normal bowel sounds
e. Reproduction of his right lower quadrant abdominal pain with internal rotation of his flexed right hip

e. Reproduction of his right lower quadrant abdominal pain with internal rotation of his flexed right hip

A 65 year old male presents to the emergency room with 12 hours of right lower quadrant pain, leukocytosis, and anorexia. His pain began as periumbilical, vague pain and progressed over the last 8 hours to focal pain in the right lower quadrant. It is during this time period that he lost his appetite. He does not feel ill. Has no fever. On physical exam, he has point tenderness and guarding two-thirds of the distance from his umbilicus to his right anterior superior iliac spine. Based on this history and physical exam, he is diagnosed with typical acute appendicitis and is taken to surgery for laparoscopic appendectomy. The surgeon describes the appendix as normal appearing. Appendectomy is performed without complication. Final pathological analysis of his surgical specimen shows a normal appendix. The rate of misdiagnosis, or negative appendectomy, in this situation is best described as:

15%
35%
5%
65%
50%

65%

A 25 year old male is seen in the emergency room with focal right lower quadrant pain. He had mild abdominal discomfort last night which he has difficulty specifically describing. This morning, he had severe right lower quadrant pains which he says are much worse. He has no fever. His WBC is 14k with 90% PMNs. CT scan of the abdomen and pelvis identifies an inflamed appendix with an appendicolith. He is evaluated by a surgeon who confirms the diagnosis of appendicitis and he is taken to surgery for appendectomy. He is found to have typical, non-perforated appendicitis. Which of the follow best describes the appropriate use of antibiotics in this patient?

a. Antibiotics should be given orally
b. Antibiotics should be continued post-operatively until the patient's WBC returns to normal
c. A single dose of antibiotic pre-operatively is necessary
d. Antibiotics should be given pre-operatively and for no more than 24 hours post-operatively
e. Antimicrobials are not necessary for non-perforated appendicitis

d. Antibiotics should be given pre-operatively and for no more than 24 hours post-operatively

A patient arrives to the emergency room complaining of right lower quadrant pain which was present when they awoke this morning and has remained constant. No other symptoms are reported. The WBC count is 16k with 89% PMNs. Temperature is 37.9C. All other lab values are normal. Abdominal exam finds focal tenderness in the right lower quadrant with guarding and rebound tenderness. This tenderness, although somewhat less, is reproduced with deep palpation and release of the left side of the abdomen.
This history and exam, in which of the following patients, warrants immediate surgery and no further testing.

a. A 25 year old male who reports being hungry despite his pain.
b. A 31 year old male who tells you vomited once early this morning and remains anorexic.
c. A 28 year old female who has a history of Crohn's enteritis.
d. A 27 year old female who is married and reports her LMP was about two weeks ago.
e. A 28 year old male who is morbidly obese and vomited once early this morning and is now hungry

A 31 year old male who tells you vomited once early this morning and remains anorexic.

The diagnosis of appendicitis should be questioned if the patient is not anorexic.

A 29 year old female presents to the emergency department during her 25th week of pregnancy with new onset of focal right lower quadrant pain. The pain has been constant for 8 hours. She vomited earlier and has not eaten today. A temperature of 37.5C is recorded. WBC is 16k. Ultrasound shows free fluid in the right lower quadrant, and an appendix dilated to 15mm. This exam also shows a normal, viable, intra-uterine pregnancy. Which of the following statements is true regarding her diagnosis and treatment options?

a. This is the second most common surgical emergency in pregnancy.
b. The leukocytosis in this patient should be considered normal.
c. Regardless of treatment, there is at least a 25% rate of early delivery.
d. CT scan of the abdomen/pelvis is necessary for definitive diagnosis.
e. Diagnostic laparoscopy is not an option due to pregnancy

b. The leukocytosis in this patient should be considered normal.

Physiologic leukocytosis in normal pregnancy is up to 16k.
Acute appendicitis is the most common surgical emergency in pregnancy.

25 year old man presents with 18 hours of anorexia and peri-umbilical abdominal pain, now localized in the right lower quadrant. On exam he has a temperature of 101, HR 80, BP 124/82 and 02 saturation 98% on room air. His WBC is 14, the rest of his labs are normal. His CT scan shows "inflammation in the right lower quadrant - cannot differentiate acute appendicitis from sigmoid diverticulitis." The next step in his management should be:

a. Order a water soluble enema to evaluate for diverticulitis
b. Proceed urgently to the operating room for appendectomy
c. Order blood cultures and admit for observation and antibiotics
d. Discuss case with radiologist to see what additional testing would be helpful
e. consider sending IBD (inflammatory bowel disease) blood panel

b. Proceed urgently to the operating room for appendectomy

patient has a classic constellation of symptoms for appendicitis and he is the wrong age for diverticulitis which usually affects older patients

75 year old female with 4 weeks of intermittent post prandial right upper quadrant abdominal pain was seen by her primary care physician who ordered a CT scan and sent her home. He calls you urgently because the CT scan was read as "cholelithiasis with dilated appendix suspicious for acute appendicitis." The next step in management should be:

a. Call the patient and schedule her for an elective colonoscopy
b. Call the patient and schedule her for urgent appendectomy
c. Call the patient and schedule her for urgent cholecystectomy
d. Call the patient and tell her to come to the emergency room
e. call the patient and ask to her to proceed to the lab for IBD testing

a. Call the patient and schedule her for an elective colonoscopy

This patient does not have a history consistent with appendicitis - her history is that of biliary colic - which is confirmed with the ct scan findings of cholelithiasis.

21 year old female comes in with 12 hours of pain that began around the umbilicus and migrated to the right lower quadrant. She has a fever of 101, a white blood cell count of 13 and right lower quadrant peritonitis on exam. Urine HCG and pelvic exam is negative. The most appropriate discussion to have with the patient next is:
a. Discuss with the patient increased risk of infertility associated with appendectomy
b. Discuss with the patient the risk of abscess formation associated with appendectomy surgery
c. Discuss with the patient risks of C. diff colitis with antibiotics
d. Discuss with the patient the risk of death associated with appendectomy surgery
e. Discuss the risk of needing a temporary colostomy

b. Discuss with the patient the risk of abscess formation associated with appendectomy surgery

17 year old male high school sprinter, presents to the emergency room with worsening right lower quadrant abdominal pain and nausea over the last 24 hours. He had a documented fever of 101 at home. Currently, his vital signs are normal except for a heart rate of 105 and a temperature of 100.5. He has right lower quadrant peritonitis on exam at McBurney's point. White blood cell count is 13,000 and CT scan is indeterminate for appendicitis due to non-visualization of the appendix. The next step should be:
a. Discharge the patient for follow up with his primary care with a diagnosis of gastroenteritis
b. Obtain consultation from Gastroenterology
c. Ask the lab to perform a differential on the white blood cell count
d. Consent the patient and mother for an appendectomy
e. Admit the patient for observation and serial exam

d. Consent the patient and mother for an appendectomy

An 80-year-old woman who resides in a nursing home is brought to the emergency department for a 2-day history of abdominal distention and obstipation. She has no history of previous surgeries. Her current medications are ibuprofen and omeprazole.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 80/min and regular, respirations are 24/min, and blood pressure is 149/80 mm Hg. No murmurs are heard, and the lungs are clear to auscultation and percussion. The abdomen is markedly distended and tympanitic with diffuse tenderness but no rebound. Rectal examination shows no stool.
Plain abdominal x-ray shows a markedly distended, coffee bean-shaped loop of bowel with haustral markings in the right upper quadrant.

Which of the following is the most likely diagnosis?

a. Small bowel obstruction
b. Gallstone ileus
c. Ogilve's pseudo-obstruction
d. Sigmoid volvulus
e. Diverticulitis

Sigmoid volvulus

An 80-year-old woman who resides in a nursing home is brought to the emergency department for a 2-day history of abdominal distention and obstipation. She has no history of previous surgeries. Her current medications are ibuprofen and omeprazole.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 80/min and regular, respirations are 24/min, and blood pressure is 149/80 mm Hg. No murmurs are heard, and the lungs are clear to auscultation and percussion. The abdomen is markedly distended and tympanitic with diffuse tenderness but no rebound. Rectal examination shows no stool.

Plain abdominal x-ray shows a markedly distended, coffee bean-shaped loop of bowel with haustral markings in the right upper quadrant.

PART B: With a highly suspected diagnosis of sigmoid volvulus, which of the following is the best next step in management?

a. Computed tomography of the abdomen
b. Mesenteric angiography
c. Saline enema
d. Nasogastric tube with intravenous hydration
e. Sigmoidoscopy

Sigmoidoscopy

Sigmoid volvulus is a form of large bowel obstruction that is ideally decompressed prior to definitive management (surgery to avoid recurrence).
Decompression allows for time to resuscitate, and possibly bowel prep the patient, but surgical management is still recommended (preferably during the same hospitalization) since eventual recurrence of the volvulus is high.

A 63-year-old woman comes to the emergency department because of a 2-day history of increasing abdominal distention and obstipation. She has vomited twice in the past 8 hours. She has a 2-month history of diffuse, dull lower abdominal pain. She has noted a recent change in bowel habits, characterized by passing hard, pellet-like stools alternating with loose stools. She has lost 5 lb (2.2 kg) over the past 2 months. She has osteoarthritis and frequent episodes of heartburn. Her current medications are ibuprofen and omeprazole.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 18/min, and blood pressure is 118/80 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. Abdominal examination shows distention with high-pitched, tinkling bowel sounds and diffuse, mild tenderness.

Which of the following is the most likely diagnosis?
a. Colon cancer
b. Small bowel obstruction
c. Fecal impaction
d. Colonic Crohn's disease
e. Sigmoid volvulus

Colon cancer

A 72-year-old woman is brought to the emergency department for a 24-hour history of nausea and abdominal fullness. Her last bowel movement was 2 days ago; she has had no blood in her stool. At the age of 49 years, she underwent cholecystectomy and total hysterectomy for uterine cancer, followed by pelvic radiation therapy. She has a 20-year history of rheumatoid arthritis treated with prednisolone, 5 mg daily.

On physical examination, her temperature is 98.4°F (36.9°C), pulse is 66 beats/min, respirations are 14/min, and blood pressure is 120/58 mm Hg. The abdomen is distended without guarding or rebound tenderness. Bowel sounds are increased and tinkling. Laboratory studies show a leukocyte count of 11,500/mm3 and a serum albumin level of 2.5 mg/dL.

Acute abdominal series shows dilated loops of small bowel; no other abnormalities are noted.

Which of the following is the most likely diagnosis?
a. Ulcerative colitis
b. Gallstone ileus
c. Enteritis secondary to radiation therapy
d. Intussusception
e. Crohn's disease

Enteritis secondary to radiation therapy

A 40-year-old woman comes to the emergency department because of a 2-day history of severe periumbilical, colicky pain and abdominal distention. She is nauseated and has vomited light green vomitus 6 times in the past 24 hours. She has not passed stools or flatus for 48 hours. Her medical history is remarkable only for abdominal hysterectomy 8 years ago.

On physical examination, her temperature is 100.4°F (38°C), pulse is 110/min and regular, respirations are 24/min, and blood pressure is 120/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. The abdomen is distended and mildly tender to deep palpation. Bowel sounds are high pitched and tinkling.

Which of the following is the most likely diagnosis?

Adhesive small bowel obstruction
Crohn disease
Diverticulitis
Viral enteritis
Colon cancer

Adhesive small bowel obstruction

A 25-year-old man comes to the emergency department because of a 4-week history of increasingly severe bloody diarrhea and abdominal pain without fever or chills. He has been obstipated over the past 24 hours. He has had 2 previous episodes of less severe symptoms that were treated on an outpatient basis. With the exception of an appendectomy at the age of 12 years, he has no other significant medical history and he takes no medications.
On physical examination, his temperature is 97.7°F (36.5°C), pulse is 90/min, respirations are 22/min, and blood pressure is 130/90 mm Hg. The abdomen is distended and mildly tender in the right lower quadrant without guarding or rebound. Laboratory studies show a leukocyte count of 11,300/Î¼L and hemoglobin of 12 g/dL.

Which of the following is the most likely diagnosis?
a. Meckle's diverticulitis
b. Colon cancer
c. Yersinia enterocolitis
d. Crohn's disease
e. Adhesive small bowel obstruction

Crohn's disease

A 72-year-old woman comes to the emergency department with a 2-day history of vomiting and intermittent colicky abdominal pain. She has not had any recent weight loss. For the past 10 years, she has had postprandial upper abdominal pain that resolves with self medication with an analgesic. She has no other significant medical history, and she takes no other medications.

On physical examination, her temperature is 96.8°F (36.0°C), pulse is 90/min and regular, respirations are 22/min, and blood pressure is 130/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. The abdomen is distended and mildly tender to deep palpation. Bowel sounds are high pitched and tinkling. A plain radiograph of the abdomen shows branching air collections projecting over the liver with distended small bowel and decompressed colon.

Which of the following is the most likely diagnosis?

a. Gallstone ileus
b. Adhesive small bowel obstruction
c. Internal hernia
d. Diverticulitis
e. Lymphoma

Gallstone ileus

The presence of air in branching pattern over the liver is characteristic of biliary air seen in patient presenting with small bowel obstruction due to a gallstone that is typically stuck at the ileo-cecal valve.

A previously healthy 22-month-old boy is brought to the emergency department because of paroxysms of severe colicky abdominal discomfort that has persisted for 24 hours. His mother reports that he passed maroon-colored stool earlier today. He has not had fever.
The patient's temperature is 98.6°F (37.0°C), pulse is 90/min, respirations are 24/min, and blood pressure is 105/80 mm Hg. On cardiac examination, S1 and S2 are normal, and no murmurs are heard. The lungs are clear to auscultation. Abdominal examination shows distention and right-sided fullness. Laboratory studies show a leukocyte count of 7800/mm3. An abdominal radiograph shows dilated loops of small bowel.

Which of the following is the best next step in diagnosis?
a. Upper gastrointestinal series with water-soluble contrast
b. Barium enema
c. Colonoscopy
d. Computed tomography of the abdomen
e. Surgical exploration

Barium enema- intussusception

A 45-year-old woman comes to the emergency department because of a 2-day history of severe periumbilical, colicky pain and abdominal distention. She is nauseated and has vomited light green vomitus 6 times in the past 24 hours. She has not passed stools or flatus for 48 hours. Her medical history is remarkable only for appendectomy at the age of 14 years.

On physical examination, her temperature is 100.4°F (38.0°C), pulse is 100/min and regular, respirations are 24/min, and blood pressure is 120/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. The abdomen is distended and mildly tender with rebound on deep palpation. Bowel sounds are rare and high pitched.

Laboratory studies show a leukocyte count of 15,000/mm3. Plain films of the abdomen show dilated proximal small bowel with pneumatosis.

A nasogastric tube is placed and intravenous fluids are begun. Which of the following is the best next step in management?

a. Barium enema
b. Computed tomography of the abdomen
c. Exploratory laparotomy
d. Upper gastrointestinal series with water-soluble contrast
e. Observation only

Exploratory laparotomy

Presence of peritoneal signs and pneumoatosis on x-rays are concerning for compromised or dead bowel. Especially in light of the leukocytosis and low grad temperature.

A 60-year-old man is evaluated for a 5-day history of lower abdominal pain and tenesmus. For the past 2 days, the abdominal pain has increased, and he has had nausea without vomiting. He has 2 previous episodes of similar symptoms that were treated on an outpatient basis. The patient has a history of chronic constipation that he manages with magnesium hydroxide.

On physical examination, his temperature is 100.8°F (38.2°C), pulse is 90/min and regular, respirations are 16/min, and blood pressure is 140/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. There is significant tenderness in the left lower quadrant with guarding but no rebound. Laboratory studies show a leukocyte count of 12,400/mm3 and hemoglobin of 12 g/dL.

Which of the following is the most likely diagnosis?
a. Diverticulitis
b. Sigmoid volvulus
c. Carcinoma of the colon
d. Ischemic colitis
e. Crohn disease

Diverticulitis often presents with low grade temps, left lower quadrant pain and tenderness, and leukocytosis.

A 60-year-old man is evaluated for a 5-day history of lower abdominal pain and tenesmus. For the past 2 days, the abdominal pain has increased, and he has had nausea without vomiting. He has 2 previous episodes of similar symptoms that were treated on an outpatient basis. The patient has a history of chronic constipation that he manages with magnesium hydroxide.

On physical examination, his temperature is 100.8°F (38.2°C), pulse is 90/min and regular, respirations are 16/min, and blood pressure is 140/90 mm Hg. No murmurs are heard. The lungs are clear to auscultation and percussion. The abdomen is distended with high-pitched tinkling bowel sounds. There is significant tenderness in the left lower quadrant with guarding but no rebound. Laboratory studies show a leukocyte count of 12,400/mm3 and hemoglobin of 12 g/dL.

A nasogastric tube is placed and intravenous fluids are begun. Which of the following is the most appropriate next step in management?

a. Mesenteric angiography
b. Barium enema
c. Exploratory laparotomy
d. Colonoscopy
e. Computed tomography of the abdomen

Computed tomography of the abdomen

A 44-year-old woman who underwent laparoscopic cholecystectomy 36 hours ago comes to the emergency department because of a 8-hour history of severe periumbilical pain. She is nauseated and has vomited 4 times in the past 12 hours.

On physical examination, the trochar site appears clean. Her temperature is 101.3°F (38.5°C), pulse is 118/min and regular, respirations are 22/min, and blood pressure is 120/90 mm Hg. No murmurs are heard. Diffuse crackles are heard at the bases of both lungs. The abdomen is distended and diffusely tender to palpation and percussion.

Laboratory studies show a serum bilirubin of 0.8 mg/dL. Hepatobiliary iminodiacetic acid (HIDA) scan shows no evidence of a bile leak.

Which of the following is the best next step in management?

a.Exploratory laparotomy
b. Computed tomography of the abdomen
c. Abdominal ultrasound
d. Observation and antibiotic therapy
e. Upper gastrointestinal series with water-soluble contrast

Exploratory laparotomy.

Patient is presenting with a picture of systemic sepsis and an acute abdomen

A 36-year-old otherwise healthy man presents to the emergency room with a 24-hour history of diffuse abdominal pain, obstipation, nausea and emesis. His past medical history is significant for an open appendectomy at the age of 5 years.

On examination, temperature is 99.6°F (37.6°C), pulse is 110/min, respirations are 22/min, and blood pressure is 110/70 mm Hg. The abdomen is distended, bowel sounds are high pitched and metallic, percussion is tympanitic, and there is tenderness to palpation over all 4 quadrants.

Which of the following is the most likely cause of his obstruction?

a. Malrotation
b. Internal hernia
c. Cancer
d. Adhesions
e. Intussusception

Adhesions

An 80-year-old woman is evaluated for a 2-day history of nausea, vomiting, and abdominal distention and pain. Her medical history is remarkable for type 2 diabetes mellitus treated with metformin. She resides in an assisted living facility where she has fallen 3 times in the past year.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 70/min and regular, respirations are 16/min, and blood pressure is 140/60 mm Hg. The abdomen is distended with diffuse tenderness and tympany on percussion. While internally rotating the flexed right hip, she complains of pain extending down the medial aspect of the right thigh.

Which of the following is the most likely diagnosis?

Cecal carcinoma
Acute appendicitis
Pelvic fracture
Obturator hernia
Psoas abscess

Obturator hernia

The physician exam is consistent with a strangulated hernia, obturator hernia in this case.

A 23-year-old woman presents to the emergency department with a 2-day history of cramping abdominal pain, nausea, and vomiting. She also reports passing dark stools. Upon questioning, she recalls having similar episodes during the past two years, each of which resolved spontaneously without treatment. She has no history of abdominal operations. She takes no medications.

On physical examination, her temperature is 98.4°F (36.9°C), pulse is 122/min, respirations are 22/min, and blood pressure is 132/69 mm Hg. She has abdominal distention and diffuse tenderness without rebound or guarding. A stool specimen is positive for occult blood.

Contrast-enhanced computed tomography is most likely to show inflammation of which portion of the intestine?

a. Distal third of the descending colon
b. Transverse colon
c. Mid-jejunum
d. Stomach
e. Terminal ileum

Terminal ileum -Crohn's

Evaluate with CT scan

A 65-year-old man with recently diagnosed unresectable gastric cancer presents to the emergency department because of a 4-day history of nausea, bilious emesis, and epigastric pain. The patient has elected to not pursue chemotherapy treatment at this time.

On physical examination, his temperature is 98.0°F (36.7°C), pulse is 130/min, respirations are 28/min, and blood pressure is 100/55 mm Hg. The mucus membranes are dry. Abdominal examination shows upper abdominal distention with tympany. No peritoneal signs are noted.

Results of laboratory studies are most likely to show which of the following?

a. Hyperkalemia
b. Lactic acidosis
c, Aciduria
d. Hyperchloremia
e. Unconjugated hyperbilirubinemia

Aciduria

ou are asked to evaluate a 74-year-old woman who was admitted to the hospital 16 hours ago because of nausea, bilious emesis, and abdominal distention that persisted for 24 hours. She has moderate hypertension that is well controlled with a calcium channel blocker. Her surgical history is remarkable for an appendectomy at age 19 years and total abdominal hysterectomy for uterine leiomyoma at age 47 years.

On physical examination, her temperature is 98.8°F (37.1°C), pulse is 70/min, respirations are 14/min, and blood pressure is 130/65 mm Hg. The abdomen is tympanitic to percussion. There is minimal tenderness to palpation in the epigastrium, and rectal tone is normal. A nasogastric tube is draining clear bilious material.

Which of the following is the most appropriate next step in management?
a. Diagnostic laparoscopy
b. Colonoscopy
c. Placement of a rectal tube
d. Continued observation
e. Upper GI series

d. Continued observation

A 56-year-old man with type 2 diabetes mellitus underwent an exploratory laparotomy with lysis of adhesions and resection for a small bowel obstruction 4 days ago. His only medications are insulin and oral analgesics.

On physical examination, the temperature is 103.3°F (39.6°C), pulse is 110/min and regular with no murmur, respirations are 18/min, and blood pressure is 110/70 mm Hg. Breath sounds are decreased bilaterally. The abdomen is soft; there is tenderness at the middle of the incision, which is hyperemic.

Which of the following is the most appropriate next step in management?
Obtain computed tomography of the abdomen
Begin broad-spectrum antibiotics
Order vigorous respiratory therapy
Continue to observe
Open the incision

open the incision

A previously healthy 68-year-old white woman presents to her primary care physician 3 days after being treated in the local emergency department for a Colles fracture of her right wrist. A radiograph of her spine taken in the emergency department after her fall also showed diffuse osteopenia and new kyphoscoliosis. She takes ibuprofen as needed for mild arthritis-type pain; she also take a multivitamin and omega-3 fish oil capsule daily.
On physical examination today, the patient's right arm is in a cast. She is 63 in (160 cm) tall (10 years ago: 64 in [163 cm]) and weighs 102 lb (46 kg). Her temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 16/min, and blood pressure is 128/84 mm Hg. Moderate kyphoscoliosis is noted. The remainder of the physical examination is otherwise unremarkable.

Which of the following is the most appropriate imaging modality for this patient?
a. Neck ultrasound
b. Sestamibi scan for hyperparathyroidism
c. Positron emission tomography
d. Dual-energy x-ray absorptiometry
e. Repeat plain radiograph of the right forearm

d. Dual-energy x-ray absorptiometry

This patient most likely has osteoporosis so a DEXA scan would allow quantification of the severity of this osteoporosis.

A 65-year-old woman is referred for evaluation of a 4-year history of worsening fatigue and memory loss. She has noticed that she is becoming increasingly forgetful, occasionally walking into a room and realizing that she is unsure why she is there. Her current medications are atenolol and simvastatin. She has no relevant family history.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 94/min and regular, respirations are 20/min, and blood pressure is 136/88 mm Hg. On palpation of the neck, a 2-cm, soft, non-pulsatile mass is noted in the anterior potion of the right lobe of the thyroid. Neurologic examination shows diminished reflexes bilaterally, and the patient has difficulty rising from a chair.

Laboratory studies:
Serum calcium 12.1 mg/dL (normal: 8.5-10.3 mg/dL)

Serum phosphorus 2.0 mg/dL (normal: 2.5-4.5 mg/dL)

Serum intact parathyroid hormone 200 pg/mL (normal: 10-55 pg/mL)

Serum vitamin D 50 ng/mL (normal: 30-74 ng/mL)

PART A: Which of the following is the most likely cause of this woman's hypercalcemia?

a. Squamous cell cancer of the lung
b. Thyroid nodule
c. Parathyroid adenoma
d. Parathyroid cancer
e. Metastatic cervical lymph node

c. Parathyroid adenoma

An 80-year-old man is referred for evaluation of hypercalcemia and an elevated serum parathyroid hormone level. The patient has hypertension and osteoarthritis but no history of gallbladder disease, osteoporotic fractures, or kidney stones. His current medications are amlodipine for mild hypertension and simvastatin for hyperlipidemia. He has a daughter who was also recently found to have hypercalcemia.

On physical examination, the patient appears thin and frail. His temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 12/min, and blood pressure is 136/86 mm Hg. No masses are palpated in the neck. The remainder of the physical examination is unremarkable.

Laboratory studies:
Serum calcium 11.1 mg/dL (normal: 8.9-10.1 mg/dL)

Serum phosphorus 2.7 mg/dL (normal: 2.5-4.5 mg/dL)

Serum magnesium 1.8 mg/dL (normal: 1.7-2.1 mg/dL)

Serum creatinine 0.8 mg/dL (normal: 0.6-1.1 mg/dL)

Serum intact parathyroid hormone 75 pg/mL (normal: 10-55 pg/mL)

Ultrasound of the thyroid shows no abnormalities. A Tc99m-Sestamibi scan of the parathyroid glands shows no uptake.

Which of the following is the best next step in management?

a. A 24-hour urinary calcium measurement
b. Repeat imaging studies in 6 months
c. 4-D computed tomography of the neck
d. Subtotal parathyroidectomy
e. No further action is needed at this time

A 24-hour urinary calcium measurement

If familial hypercalcemia hypocalciuria is ruled out with the 24-hour urinary test, then the surgeon should discuss with the patient about a bilateral four-gland operation for likely parathyroid hyperplasia versus taking no action at this time and repeating imaging tests in six months or trying a new imaging modality.

A 55-year-old woman with a history of T2N1M0 estrogen receptor-negative, progesterone receptor-positive breast cancer presents to her medical oncologist 1 week after passing a ureteral stone. She underwent modified radical mastectomy of the right breast 8 months ago and completed chemotherapy with doxorubicin, paclitaxel, and cyclophosphamide 4 months ago.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 80/min, respirations are 15/min, and blood pressure is 120/66 mm Hg. Several hard masses are palpated beneath the surgical scar.

Laboratory studies:
Serum calcium 12.1 mg/dL (normal: 8.9-10.1 mg/dL)

Serum phosphorus 2.0 mg/dL (normal: 2.5-4.5 mg/dL)

Serum intact parathyroid hormone 25 pg/mL (normal: 10-55 pg/mL)

Serum parathyroid hormone-related peptide 28 pmol/L (normal: <1.5 pmol/L)

Which of the following is the most likely underlying cause of her hypercalcemia?

a. Sarcoidosis
b. Addison's disease
c. Hypercalcemia of malignancy
d. Primary hyperparathyroidism
e. Paget's disease

c. Hypercalcemia of malignancy

A 40-year-old woman is referred for evaluation of hyperparathyroidism after routine laboratory studies showed an elevated serum calcium level. She is asymptomatic and has no family history of thyroid disease. The patient expresses concern about undergoing extensive testing because her medical insurance has a high deductible.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 16/min, and blood pressure is 128/84 mm Hg. The remainder of the physical examination is unremarkable.

To localize the abnormal parathyroid gland before surgery, which of the following is the least invasive preliminary study?
a. Magnetic resonance imaging of the neck and chest
b. 4-D computed tomography
c. Cervical ultrasonography
d. Planar sestamibi scanning
e. Parathyroid venous sampling

Cervical ultrasonagraphy -

Painless, relatively quick procedure that can be performed in the endocrine surgeon's office or in radiology. The other imaging options all require intravenous access and are therefore more invasive.

72-year-old man with chronic kidney failure secondary to type 2 diabetes mellitus is evaluated for a 3-week history of worsening fatigue and joint pain. He currently requires 3 hemodialysis sessions weekly. He adheres to his current medication regimen of atenolol, lisinopril, a phosphate binder, metformin, atorvastatin, omeprazole, and neurontin.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 89/min, respirations are 14/min, and blood pressure is 140/86 mm Hg. Examination of the right arm shows a well-functioning arteriovenous fistula. The remainder of the examination is unremarkable.

Laboratory studies:
Serum calcium 11.2 mg/dL (normal: 8.9-10.1 mg/dL)

Serum phosphorus 4.7 mg/dL (normal: 2.5-4.5 mg/dL)

Serum intact parathyroid hormone 68 pg/mL (normal: 10-55 pg/mL)

PART A: Which of the following is the most likely cause of the hypercalcemia?

a. Primary hyperparathyroidism
b. Secondary hyperparathyroidism
c. Tertiary hyperparathyroidism
d. Quaternary hyperparathyroidism
e. Parathyroid carcinoma

PART B: What would be the best initial treatment of his hypercalcemia?
a. Increase frequency of hemodialysis
b. Schedule focused parathyroidectomy
c. Schedule 3.5-gland parathyroidectomy
d. Start cinacalcet
e. Increase dose of phosphate binder

A- secondary hyperparathyroidism is hyperparathyroidism in a patient with chronic kidney disease or vitamin D deficiency

B-Cinacalcet is a calcimimetic and is first line treatment for patients with secondary hyperparathyroidism.

42-year-old man is referred to a gastroenterologist for peptic ulcer disease that has been refractory to medical therapy. An endoscopic evaluation 3 weeks ago showed multiple duodenal ulcers. Eight years ago, he underwent transphenoidal resection of a pituitary adenoma. He has passed 2 ureteral stones during the past 2 years. His current medications are omeprazole and a daily multivitamin.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 14/min, and blood pressure is 124/72 mm Hg. No thyroid masses are palpated.

Laboratory studies:
Serum gastrin 432 pg/mL (normal: <100 pg/mL)
Serum calcium 14.8 mg/dL (normal: 8.9-10.1 mg/dL)

Which of the following is the most likely underlying diagnosis?
MEN syndrome, type I
MEN syndrome, type IIB
MEN syndrome, type III
MEN syndrome, type IIC
MEN syndrome, type IIA

MEN syndrome, type I (Wermer's Syndrome) is an autosomal dominant disease that results in tumors of the pituitary, pancreas, and parathyroid glands.

An 85-year-old woman is referred for evaluation of incidental hypercalcemia noted on her last physical examination. She reports having persistent fatigue, increasing memory loss, and occasional constipation during the past several months. She has a long history of hypertension and hyperlipidemia treated with metoprolol and atorvastatin.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 78/min, respirations are 18/min, and blood pressure is 148/82 mm Hg. The remainder of the physical examination shows no abnormalities.

Laboratory studies:

Serum calcium 11.1 mg/dL (normal: 8.9-10.1 mg/dL)

Serum phosphorus 2.3 mg/dL (normal: 2.5-4.5 mg/dL)

Serum intact parathyroid hormone 55 pg/mL (normal: 10-55 pg/mL)

Urine calcium 280 mg/24 hr (normal: 20-275 mg/24 hr)

Ultrasound of the neck is normal. A Tc99m Sestamibi-scan of the parathyroid glands shows no uptake.

PART A: Exploratory surgery is most likely to reveal which of the following?

a. Four normal parathyroid glands
b. Parathyroid adenoma
c. Parathyroid carcinoma
d. Four hyperplastic parathyroid glands
e. Parathyroid cyst

Four hyperplastic parathyroid glands

patient's history and laboratory findings are consistent with primary hyperparathyroidism.

The patient undergoes successful removal of 3.5 glands. Eight hours after the procedure, she reports severe numbness around her mouth and tingling in the fingertips of both hands that does not resolve with 1 gram of elemental calcium. Examination of the surgical site shows no evidence of hematoma. Repeat laboratory studies show:

Serum calcium 7.2 mg/dL (normal: 8.9-10.1 mg/dL)

Serum phosphorus 1.9 mg/dL (normal: 2.5-4.5 mg/dL)

Serum magnesium 1.4 mg/dL (normal: 1.7-2.1 mg/dL)

Serum potassium 2.7 mg/dL (normal: 3.5-5.5 mg/dL)

PART B: Which of the following is the most likely diagnosis?

a. Paradoxical hypokalemia
b. Parathyroid "storm"
c. Continued hyperparathyroidism
d. Hungry bone syndrome
e. Hyperthyroidism

Hungry bone syndrome

Constellation of hypocalcemia, hypophosphatemia, and hypomagnesemia after successful parathyroidectomy due to the sudden withdrawal of excess PTH. Parathyroidectomy for hyperparathyroidism may result in an imbalance between osteoblast-mediated bone formation and osteoclast-mediated bone resorption that results in rapid absorption of calcium, phosphate, and magnesium into the bones.

A 58-year-old woman is evaluated for recurrent hyperparathyroidism 3 years after undergoing parathyroidectomy for primary hyperparathyroidism. The patient reports bone pain affecting her arms and legs. The prior operative report confirms the removal of a parathyroid adenoma but notes spillage of the adenoma during resection. The patient takes vitamin D and a multivitamin but no other medications.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 74/min, respirations are 16/min, and blood pressure is 128/84 mm Hg. The cervical neck incision is well healed, but several nodules are palpated over the right sternohyoid and sternocleidomastoid muscles. The remainder of the examination is unremarkable.

Laboratory studies:
Serum calcium 11.9 mg/dL (normal: 8.9-10.1 mg/dL)

Serum phosphorus 2.3 mg/dL (normal: 2.5-4.5 mg/dL)

Serum intact parathyroid hormone 180 pg/mL (normal: 10-55 pg/mL)

Urine calcium 400 mg/24 hr (normal: 20-275 mg/24 hr)

Which of the following is the most likely cause of the persistently elevated parathyroid hormone level?

a. Familial hyperparathyroidism
b. MEN syndrome, type IIA
c. MEN syndrome, type IIB
d. Ectopic parathyroid adenoma
e. Parathyromatosis

Parathyromatosis is caused by the rupture and/or spillage of hyperfunctioning parathyroid cells into the operative bed during an initial operation. If the cells remain hyperfunctioning they cause recurrent hyperparathyroidism and present as multiple random nodules within the original operative field.

A previously healthy 49-year-old woman is evaluated for a 3-day history of right arm weakness and difficulty speaking. Medical history is remarkable for hypertension, hypercholesterolemia, and type 2 diabetes mellitus. Current medications are atorvastatin, lisinopril, and metformin.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 22/min, and blood pressure is 190/100 mm Hg. Neurologic examination shows right upper extremity weakness (4/5). Her speech is hesitant, and she has difficulty finding words.

Magnetic resonance angiography shows 60% narrowing of both carotid arteries Magnetic resonance imaging of the brain shows a hemorrhagic infarct in the left parietal lobe.

Which of the following is the most appropriate initial treatment?

a. Intravenous corticosteroids
b. Left carotid endarterectomy
c. Left carotid stent
d. Heparin and oral antiplatelet medications
d. Control of hypertension

Control of hypertension

A 71-year-old man is evaluated for lightheadedness and weakness of the right arm since he awoke this morning. He reports trying to reach for his watch, "but my arm didn't respond to my brain's command." He dismissed the incident and went back to sleep. Two hours later, he awakened and was able to get out of bed without difficulty. At this time, his arm felt normal. He has no history of similar episodes. The patient, who has a 30-pack-year smoking history, has hypertension and hypercholesterolemia, and he sustained a myocardial infarction 6 years ago. He underwent coronary stent placement at that time. Current medications are aspirin, lisinopril, atorvastatin, and occasional ibuprofen for muscle pain.

On physical examination, the patient is not feeling lightheaded. temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 22/min, and blood pressure is 140/76 mm Hg. No bruits are heard. Muscle strength is 4 bilaterally. Neurological examination reveals no evidence of motor or sensory deficits.

A -Which of the following is the most likely diagnosis?
a. Intracranial cerebral aneurysm
b. Transient ischemic attack
c. Hemorrhagic stroke
d. Intracranial brain tumor
e. Ischemic stroke

B- Which of the following is the best next step in management?
a. Echocardiogram
b. Magnetic resonance imaging (MRI) of the brain
c. Admission for observation and anticoagulant therapy
d. Carotid ultrasound
e. Magnetic resonance angiography (MRA) of the neck

C- Which of the following guidelines will be most helpful for management of this condition?
a. North American Symptomatic Carotid Endarterectomy Trial (NASCET)
b. Carotid Revascularization Endarterectomy vs Stent Trial (CREST)
c. European Carotid Surgery Trial (ECST)
d. Asymptomatic Carotid Atherosclerosis Study (ACAS)
e. Asymptomatic Carotid Surgery Trail (ACST)

A- Transient ischemic attack
B- Carotid ultrasound
C- North American Symptomatic Carotid Endarterectomy Trial (NASCET)

Two hours after a left carotid endarterectomy, a 65-year-old woman develops tense swelling of the neck on the side of the surgical incision. While preparations are being made to return her to the operating room, she reports a "choking" sensation and becomes increasingly short of breath. She is not currently receiving any medication.

On physical examination, her blood pressure is 90/75 mmHg, pulse rate is 130/min, and respirations are 25/min and shallow. Pulse oximetry shows an oxygen saturation of 87%.

Which of the following is the most appropriate response?

a. Emergency tracheostomy
b. Intravenous midazolam
c. Prepare for transfusion of blood and blood products
d. Intubate the patient to protect the airway
e. Decompress the surgical wound immediately

e. Decompress the surgical wound immediately

One hour after uncomplicated left carotid endarterectomy, a 70-year-old man develops aphasia with right upper extremity weakness. He has received 2 mg. of morphine post-operatively for pain.

On physical examination, his temperature is 97.3°F (36.3°C), pulse is 100/min and regular, respirations are 18/min, and blood pressure is 126/76 mm Hg. On questioning, the patient has difficulty finding the right words to express himself. Muscle strength is 2/5 in the right upper extremity and 5/5 in the left. Sensation to pinprick is normal.

Which of the following is the best next step in management?

a. Heparin therapy and observation
b. Emergent CT angiography
c. Intravenous tissue plasminogen activator per stroke protocol
d. Emergent contralateral carotid endarterectomy
e. Immediate re-exploration of carotid artery

e. Immediate re-exploration of carotid artery

A 70-year-old man is evaluated for a 15-minute episode of significant weakness and inability to use his right arm. During the episode, which occurred 3 hours ago, he also had some difficulty speaking. He had a similar episode 3 days ago. He has had no other neurologic symptoms, and his weakness and speech difficulty have completely resolved. The patient has a long-standing history of hypertension and coronary artery disease, and he sustained a myocardial infarction 8 years ago. His current medications are hydrochlorothiazide and a beta blocker.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 18/min, and blood pressure is 124/70 mm Hg. He has bilateral carotid bruits. Neurologic examination shows no abnormalities. Muscle strength is 5/5 on the right and left upper and lower extremities.

Which of the following is the best next step in management?
a. Electroencephalography
b. Contrast-enhanced computed tomographic angiography
c. Cerebral angiography
d. Contrast-enhanced magnetic resonance imaging of the brain
e. Carotid duplex ultrasonography

Carotid duplex ultrasonography

A 70-year-old man is seen because of a 2-hour history of significant right arm and leg weakness and some difficulties with his speech. His symptoms have improved slightly, but he still reports weakness of his right upper and lower extremities and continues to have difficulty speaking. He has a history of type 2 diabetes mellitus and coronary artery disease. His current medications are metformin, atorvastatin, and an angiotensin-converting enzyme inhibitor.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 90/min and regular, respirations are 18/min, and blood pressure is 124/70 mm Hg. He has bilateral carotid bruits. Neurologic examination shows 4/5 weakness in the right upper and lower extremities but no sensory loss. His speech is hesitant, and he has difficulty finding the right words during conversation.

Which of the following is the best next step in management?

a. Magnetic resonance angiography
b. Electromyography of the right arm
c. Computed tomography of the head without contrast
d. Cerebral angiography
e. Electroencephalography

C. Computed tomography of the head without contrast

Prior to consideration of of lytic therapy the patient should undergo a CT scan of the head, without contrast, to exclude evidence of bleeding.

An 70-year-old man is evaluated for several episodes of transient blindness in his left eye during the past 2 weeks. Each episode lasted approximately 10 minutes. Three years ago, he underwent coronary artery bypass surgery and subsequent placement of an implantable cardiac defibrillator. His current medications are aspirin and enalapril.

On physical examination, his temperature is 98.7°F (37.1°C), pulse is 78/min and regular, respirations are 14/min, and blood pressure is 136/76 mm Hg. Funduscopic examination shows yellow highly refractile debris in the left eye. There is no evidence of sensorimotor loss in the extremities. The remainder of the examination shows no abnormalities.

Carotid duplex ultrasonography shows greater than 80% stenosis of both internal carotid arteries.

Which of the following is the best next step in management?

a. Computed tomography (CT) of the head without contrast
b. Intravascular ultrasonography of the carotids
c.Initiate therapy with intravenous heparin
d. Cardiac echocardiogram
e. Computed tomographic angiography (CTA) of the head and neck

Computed tomographic angiography (CTA) of the head and neck

An 81-year-old man presents for a yearly medical examination. Medical history is remarkable for coronary artery disease and hypertension. Current medications are aspirin and propranolol. The patient denies chest pain, shortness of breath, weight loss or abdominal discomfort, and neurological deficit.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 65/min and regular, respirations are 14/min, and blood pressure is 140/80 mm Hg. A right carotid bruit is heard; no bruits are heard on the left. The remainder of the physical examination is normal, including a complete cardiac and neurologic evaluation.

Carotid duplex ultrasonography shows greater than 80% stenosis of both external carotid arteries.

Which of the following is the best next step in management?

a. Left carotid endarterectomy
b. Balloon angioplasty and stenting of the left carotid artery
c. Angioplasty and stenting of both carotid arteries 4 weeks apart
d. Observation and anti-platelet therapy
e. Bilateral carotid endarterectomies 4 weeks apart

Observation and anti-platelet therapy.

A carotid bruit can be associated with stenoses of the internal or external carotid arteries

A 60-year-old woman is referred for evaluation after her primary care physician detected a left carotid bruit on routine physical examination. She has no history of cardiovascular disease, and she takes no medications.

On physical examination, her temperature is 98.9°F (37.2°C), pulse is 80/min and regular, respirations are 16/min, and blood pressure is 136/76 mm Hg. Carotid duplex ultrasonography shows 50% stenosis, by diameter, of the left internal carotid artery.

Which of the following is the best next step in management?
a. Anti-platelet therapy with repeat duplex scan in 12 months
b. Angioplasty and stenting of the left internal carotid artery
c. Left carotid endarterectomy
d. Computed tomographic angiography
e. Magnetic resonance angiography

Anti-platelet therapy with repeat duplex scan in 12 months

Eighteen hours after uncomplicated left carotid endarterectomy, a 65-year-old woman is found to have drooping of the left side of her mouth when asked to smile. Her only medication is aspirin.

On physical examination, her temperature is 99.3°F (37.4°C), pulse is 85/min and regular, respirations are 15/min, and blood pressure is 136/76 mm Hg. The operative site is clean without evidence of infection, and the neck is not swollen.

Which of the following is the most likely cause of this patient's facial droop?

a. Injury to the glossopharyngeal nerve
b. Injury to the left vagus nerve
c. Injury to the left hypoglossal nerve
d. Injury to the marginal mandibular branch of the left facial nerve
e. Stroke due to microemboli

d. Injury to the marginal mandibular branch of the left facial nerve

The morning following an uncomplicated left carotid endarterectomy, a 65-year-old woman reports that she bit her tongue repeatedly while chewing her food at breakfast. She is otherwise feeling comfortable. The attending physician notes that her tongue protrudes to the left side on extension. The patient has a history of coronary artery disease and takes 1 aspirin daily.

On physical examination, her temperature is 99.5°F (37.5°C), pulse is 80/min and regular, respirations are 15/min, and blood pressure is 136/80 mm Hg. The patient's tongue deviates to the left when extended. The surgical site is clean without evidence of infection, and the neck is not swollen. Neurologic examination of the extremities is normal.

Which of the following is the most likely cause of this new clinical finding?
a. Injury to the left hypoglossal nerve
b. Stroke due to microemboli
c. Injury to the glossopharyngeal nerve
d. Injury to the left vagus nerve
e. Injury to the marginal mandibular branch of the left facial nerve

a. Injury to the left hypoglossal nerve

A 63-year-old woman comes to the emergency department because of a 2-day history of fever and worsening lower abdominal pain. She has not had a bowel movement in 3 days. There is no history of nausea or vomiting. The patient had 2 similar episodes during the past year that were diagnosed as diverticulitis, and she was treated with antibiotics. She has a 10-year history of intermittent constipation and diarrhea that resolve with nonprescription medications. Her primary care physician has treated her for urinary tract infections 3 times during the last 2 months. The patient had a hysterectomy 12 years ago for uterine fibroids. Her brother underwent chemotherapy for colon carcinoma, and her paternal grandfather died of the disease.
Which of the following items elicited in the patient's history would make you suspect complicated diverticulitis?

a. History of alternating constipation and diarrhea
b. Family history of colon carcinoma
c. Three urinary tract infections in the last 2 months
d. History of no bowel movements in 3 days
e. Fever and worsening abdominal pain

c. Three urinary tract infections in the last 2 months

A 63-year-old woman comes to the emergency department because of a 2-day history of fever and worsening lower abdominal pain. She has not had a bowel movement in 3 days. There is no history of nausea or vomiting. The patient had 2 similar episodes during the past year that were diagnosed as diverticulitis, and she was treated with antibiotics. She has a 10-year history of intermittent constipation and diarrhea that resolve with nonprescription medications. Her primary care physician has treated her for urinary tract infections 3 times during the last 2 months. The patient had a hysterectomy 12 years ago for uterine fibroids. Her brother underwent chemotherapy for colon carcinoma, and her paternal grandfather died of the disease.

PART B: On physical examination, temperature is 101.3°F (38.5°C), pulse is 100/min, respirations are 18/min, and blood pressure is 130/80 mm Hg. Abdominal examination shows distention, and there is tenderness with guarding on palpation of the left lower quadrant. Bowel sounds are hypoactive. Rectal examination shows a normal anus and and empty rectum; no masses are palpated. Vaginal examination reveals left-sided tenderness.

Which of the following physical examination findings is most consistent with and specific to diverticulitis?
a. Empty rectum
b. Fever
c. Hypoactive bowel sounds
d. Left lower quadrant tenderness with guarding
e. Left-sided tenderness on vaginal examination

Left lower quadrant tenderness with guarding

A previously healthy 56-year-old man presents to the emergency department with a 12-hour history of fever and increasingly severe left-sided abdominal pain. He has not had nausea, vomiting, or diarrhea. He takes no medications.

On physical examination, temperature is 101.5°F (38.6°C), pulse is 90/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. There is focal tenderness with guarding on palpation over the left lower abdomen. The remainder of the physical examination is unremarkable.

Laboratory studies are remarkable for a leukocyte count of 12,200 cells/mm3.

Which of the following is the most appropriate next step in diagnosis?
a. Supine and upright xrays of the abdomen
b. Colonoscopy
c. Computed tomography of the abdomen
d. Laparoscopy
e. Barium enema

c. Computed tomography of the abdomen

A 45-year-old woman comes to the emergency department because of a 36-hour history of severe, cramping pain in the lower abdomen. For the past 2 days, she has noted burning on urination. She has not had a bowel movement in 3 days. Six months ago, the patient completed a course of antibiotic therapy for diverticulitis. She had a hysterectomy 5 years ago for uterine fibroids.

On physical examination, her temperature of 101.7°F (38.7°C), pulse is 100/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. Abdominal examination shows tenderness with guarding to palpation over the lower abdomen. Rectal examination shows no abnormalities. Vaginal examination shows anterior and left-sided tenderness.

Which of the following laboratory studies would be most likely to confirm that this patient has complicated diverticulitis?
a. Complete blood count
b. Liver function tests
c. C-reactive protein assay
d. Serum human chorionic gonadotropin
e. Urinalysis

urinalysis

A positive test would be consistent with a colovescicle fistula.

A 48- year-old woman comes to the emergency department because of increasing abdominal pain, chills, and fever for the past 36 hours. Six days ago, she underwent an uncomplicated laparoscopic colectomy with primary anastomosis for recurrent diverticulitis, and she was discharged on the morning of postoperative day 4. At that time, she was passing flatus and tolerating a soft diet. Later that morning, she started to feel ill. She has not had a bowel movement since discharge.

On physical examination, her temperature is 101.8°F (38.8°C), pulse is 110/min and regular, respirations are 18/min, and blood pressure is 110/70 mm Hg. The chest is clear to auscultation, and no murmurs are heard. There is moderate tenderness to palpation over the lower abdomen.

Which of the following is the most likely cause for the change in her medical condition?
a. Intra-abdominal abscess
b. Missed intraoperative ureteral injury
c. Postoperative ileus
d. Clostridium difficile colitis
e. Recurrent diverticulitis

Intra-abdominal abscess

Abscesses generally form about one week after surgery and cause fever, tachycardia, hypotension and tenderness.

An asymptomatic 50-year-old man is scheduled to undergo a routine screening colonoscopy. The patient reports that he tries to follow a healthy diet but eats at fast food restaurants 2 to 3 times weekly. His bowel habits are fairly regular, but he occasionally takes a mild laxative for episodes of constipation. He takes no other medications.

Physical examination, including digital rectal examination, shows no abnormalities. During the procedure, the endoscopist notices multiple diverticula in the left colon.

Which of the following is the best next step in management?
a. Contrast-enhanced computed tomography
b. Recommendation to avoid use of nonprescription laxatives
c. Initiation of a high-fiber diet
d. Referral for colon resection
e. Oral antibiotic therapy

Initiation of a high-fiber diet

A 52-year-old man visits his primary care physician for a routine physical examination. After obtaining the patient's personal and family medical history and performing a complete physical examination, the physician recommends the patient undergo colonoscopy.

One week later, the physician receives the patient's colonoscopy report, which indicates that multiple diverticula were observed in the sigmoid and descending colon without evidence of inflammation.

Given these findings, which of the following did the patient most likely report during his initial office visit?

a. Recent history of abdominal and anorectal pain
b. A 2-week history of constipation
c. No symptoms
d. A 2-day history of blood in the stool
e. An extensive smoking history

No symptoms

A 62-year-old woman with a 6-year history of diverticulosis presents to the emergency department with abdominal pain that began 3 days ago and is getting worse.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 110/min, respirations are 16/min, and blood pressure is 142/84 mm Hg. She appears nontoxic, although she asks if she can forego an abdominal examination because "it really hurt" when the emergency department attending physician examined her.

Which of the following physical examination findings would be most concerning for the subsequent management of this patient?

a. No pain on percussion at the costovertebral angle
b. Pain on deep palpation of all 4 quadrants
c. The patient has stool in the rectal volt.
d. The patient winces in pain when her bed is accidentally bumped
e. Absence of bowel sounds upon auscultation for 10 seconds

The patient winces in pain when her bed is accidentally bumped.

Indicates peritonitis - could indicate a free perforation which would require immediate surgery

A 62-year-old man presents to the emergency department because of a 36-hour history of left lower quadrant pain and decreased appetite. He has had diverticulosis for 10 years and previously had 2 episodes of diverticulitis that required treatment with antibiotics and bowel rest. He also has chronic obstructive pulmonary disease that is well controlled with albuterol inhalers.

On physical examination, temperature is 101.0°F (38.3°C), pulse is 110/min, respirations are 18/min, and blood pressure is 146/88 mm Hg. Pulse oximetry shows an oxygen saturation of 96%. The patient appears uncomfortable. On abdominal examination, the left lower quadrant is tender to palpation and elicits guarding. Results of laboratory studies are pending.

Which of the following is the best next step in management?

a. Contrast-enhanced computed tomography of the abdomen and pelvis
b. Colonoscopy
c. Abdominal ultrasound
d. Barium enema
e. Upright chest x-ray

Contrast-enhanced computed tomography of the abdomen and pelvis

A 72-year-old woman presents to the emergency department with a 4-hour history of intense abdominal pain preceded by 2 days of vague left lower quadrant pain and nausea. She has no history of similar episodes. Her medical history is remarkable for atrial fibrillation, hypertension, and type 2 diabetes mellitus. Her current medications are amiodarone, losartan, hydrochlorothiazide, and enalapril. She has no history of previous surgeries.

On physical examination, temperature is 101.0°F (38.4°C), pulse is 125/min and irregular, respirations are 20/min, and blood pressure is 132/86 mm Hg. Pulse oximetry shows an oxygen saturation of 99%. The abdomen is exquisitely tender to palpation of the left and right lower quadrants; a mass is appreciated in the left lower quadrant, and palpation elicits abdominal guarding. Intravenous fluids are begun, and the patient is instructed to receive nothing by mouth. Results of laboratory studies are pending.
Which of the following laboratory results would necessitate the greatest change in the subsequent management of this patient's condition?

a. Hemoglobin of 10.2 g/dL (normal: 12-15 g/dL)
b. Leukocyte count: 14,000/mm3 (normal: 4000-11,000/mm3)
c. C-reactive protein of 42 mg/L (normal: <5 mg/L)
d. Urinalysis showing 10 RBCs, 2 WBCs/hpf, leukocyte esterase positive, nitrite positive
e. Serum creatinine of 2.3 mg/dL (normal: <1.4 mg/dL)

Urinalysis showing 10 RBCs, 2 WBCs/hpf, leukocyte esterase positive, nitrite positive

An 82-year-old man presents to the emergency department after 2 episodes of bright red blood clots in his stool during the past 6 hours. He otherwise feels fine and denies any symptoms including abdominal pain. He has a history of diverticulosis, seen on multiple colonoscopies in the past, and has had a diverticular bleed in the past.

On physical examination, temperature is 97.5°F, pulse is 90/min and regular, respirations are 12/min, and blood pressure is 130/86 mm Hg. The chest is clear to auscultation, and no murmurs are heard. The abdomen is soft and nontender; bowel sounds are active.

Results of laboratory studies are pending. Anoscopy shows blood in the rectal vault; no hemorrhoids are noted.

Which of the following is the best next step in management?
a. Administration of fresh frozen plasma
b. Ultrasound of the mesenteric arteries
c. Mesenteric angiography
d. Intravenous hydration and observation
e. Exploratory laparotomy

Intravenous hydration and observation.

The patient is hemodynamically stable, so surgery at this time is not indicated.

A 58-year-old woman (gravida 3, para 3) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 12. She gave birth to her first child at age 25. There is no family history of breast or ovarian cancer.

On physical examination, there is a 2-cm, hard, irregular mass in the outer lower quadrant of the right breast, with no skin retraction or axillary lymphadenopathy. The patient chooses to undergo simple mastectomy with sentinel node biopsy instead of breast-sparing therapy. Pathologic evaluation of the tissue specimen shows a 1.9-cm infiltrating ductal carcinoma with clean surgical margins. Two sentinel nodes show no evidence of malignancy. Immunohistochemistry testing shows the tumor is HER2/neu-negative and estrogen and progesterone receptor-negative.

Which of the following is the next best step in management?
a. Endocrine therapy
b. Magnetic resonance imaging of the axilla
c. Chemotherapy
d. Complete axillary dissection
e. Radiation therapy

Chemotherapy.

Adjuvant therapy for breast cancer is treatment given after surgery when patients are at risk for recurrence.

An otherwise healthy 40-year-old woman is referred to a breast surgeon by her gynecologist because of a right breast mass she first noticed on self-examination 2 weeks ago. The mass was not present on physical examination 1 year ago. She has two children, ages 18 and 15 years. She takes a daily multivitamin and calcium supplement but no other medications, and she has no history of surgery. There is no family history of breast cancer in her family.

Physical examination is unremarkable except for a 1.5-cm firm, mobile, nontender, slightly irregular but well-defined mass in the right breast upper outer quadrant. No skin changes or dimpling are noted. There is no lymphadenopathy.

Mammography shows dense tissue but no suspicious lesions. An ultrasound of the right breast does not demostrate a cystic lesion.

Which of the following is the best next step in management?
a. Incisional biopsy
b. Fine-needle aspiration biopsy
c. Excisional biopsy
d. Wire localization biopsy
e. Core-needle biopsy

e. Core-needle biopsy

Core biopsy permits and accurate diagnosis and if positive for cancer, it allows a surgeon to discuss treatment options and plan for surgery before going to the operating room.

An otherwise healthy 40-year-old woman is referred to a breast surgeon by her gynecologist because of a right breast mass she first noticed on self-examination 2 weeks ago. The mass was not present on physical examination 1 year ago. She has two children, ages 18 and 15 years. She takes a daily multivitamin and calcium supplement but no other medications, and she has no history of surgery. There is no family history of breast cancer in her family.

Physical examination is unremarkable except for a 1.5-cm firm, mobile, nontender, slightly irregular but well-defined mass in the right breast upper outer quadrant. No skin changes or dimpling are noted. There is no lymphadenopathy.

Mammography shows dense tissue but no suspicious lesions. An ultrasound of the right breast does not demostrate a cystic lesion. Core needle biopsy demonstrates infiltrating ductal carcinoma.

Which of the following is the best next step in management?
a. Modified radical mastectomy
b. Axillary node dissection
c. Chemotherapy
d. Lumpectomy and sentinel lymph node biopsy
e. Hormonal therapy

Lumpectomy and sentinel lymph node biopsy

An otherwise healthy 40-year-old woman is referred to a breast surgeon by her gynecologist because of a right breast mass she first noticed on self-examination 2 weeks ago. The mass was not present on physical examination 1 year ago. She has two children, ages 18 and 15 years. She takes a daily multivitamin and calcium supplement but no other medications, and she has no history of surgery. There is no family history of breast cancer in her family.

Physical examination is unremarkable except for a 1.5-cm firm, mobile, nontender, slightly irregular but well-defined mass in the right breast upper outer quadrant. No skin changes or dimpling are noted. There is no lymphadenopathy.

Mammography confirms the presence of the 1.5-cm lesion but shows no other abnormalities. Pathologic examination of a core needle biopsy specimen shows estrogen and progesterone receptor-negative, HER2/neu-negative infiltrating ductal carcinoma. Lumpectomy showed clear surgical margins, and sentinel nodes were negative for carcinoma.

Which of the following is the best next step in management?
a. Hormonal therapy
b. Axillary node dissection
c. Chemotherapy followed by radiation.
d. Mastectomy
e. Observation

Chemotherapy followed by radiation.

A 62-year-old Asian woman (gravida 3, para 1) comes to the physician's office for a well-patient visit. She had a fibroadenoma removed at age 25. Menarche was at age 14 and menopause at age 52. She used oral contraceptive pills for 5 years prior to giving birth to her first child at age 32. The patient has no known medical problems and does not smoke cigarettes or drink alcohol.

Physical examination shows no abnormalities.

Which of the following is associated with the greatest increase in risk for breast cancer development in this patient?
a. History of fibroadenoma
b. Menarche at age 14
c. First birth at age 32
d. Menopause at age 52
e. Asian race

First birth at age 32

A healthy 22-year-old woman comes to the physician for evaluation of mass in the left breast discovered during breast self examination. Menarche was at age 12. She has 1 child who was born when she was 20 years of age. She has no family history of breast or ovarian cancer. Except for an oral contraceptive, which she has used for 7 years, she takes no medications.

Physical examination discloses a 1-cm, rubbery, smooth, nontender mass in the upper outer quadrant of the left breast. There is no skin retraction or lymphadenopathy.

Which of the following is the most likely diagnosis?
a. Galactocele
b. Cyst
c. Fibroadenoma
d. Abscess
e. Cancer

Fibroadenoma

Usually nontender with a rubbery feel by palpation.

A 52-year-old woman (gravida 3, para 1) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 14. She gave birth to her first child at age 25. Her maternal aunt had breast cancer diagnosed at age 75. The patient's only medication is hormone replacement, which she has taken for 5 years for severe perimenopausal symptoms.

Physical examination discloses a 1-cm, hard, irregular, nontender mass in the outer lower quadrant of the right breast. There is no skin retraction or axillary lymphadenopathy.

A- Which of the following is the most likely diagnosis?
a. Fibroadenoma
b. Fibrocystic changes
c. Abscess
d. Cyst
e. Cancer

B-Which of the following is the most appropriate next step in management?
a. Magnetic resonance imaging of the breast
b. Core-needle biopsy
c. Mammography
d. Mastectomy
e. Excisional biopsy

A- Cancer
*Hard, irregular contender mass in postmenopausal woman is cancer
B- Mammography

An otherwise healthy 42-year-old woman (gravida 3, para 2) comes to the physician for evaluation of 6-months of pain in her left breast. She has no history of previous breast problems. Menarche was at age 12. She gave birth to her first child at age 28. The patient's only medication is an oral contraceptive pill, which she has used for 5 years. There is no family history of breast or ovarian cancer.

On physical examination, there is mild tenderness in the upper outer quadrant of the left breast, but no mass is palpated. There is no nipple discharge or inversion, skin change, or lymphadenopathy. Mammogram shows a nonspecific suspicious abnormality in the upper outer quadrant of the left breast. Stereotactic core needle biopsy of the mass shows atypical ductal hyperplasia.

Which of the following is the best estimate of this woman's relative risk for breast cancer?
10.0
8.0
2.0
0.5
4.0

4.0

A 50-year-old woman comes to the physician after a diagnostic mammogram with ultrasound showed a suspicious mass in the upper outer quadrant of the left breast. Menarche was at age 11. She used oral contraceptive pills for 8 years before giving birth to her first child at age 32. Her mother had breast cancer diagnosed at age 55. There is no other family history of cancer.

On physical examination, the breasts are nontender with bilateral somewhat irregular, dense tissue but no discrete masses. There is no lymphadenopathy.

Which of the following is the most appropriate next step in management?
a. Lumpectomy
b. Incisional biopsy
c. Stereotactic core-needle biopsy
d. Mastectomy
e. Excisional biopsy

c. Stereotactic core-needle biopsy

A 56-year-old woman (gravida 1, para 1) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 12. She gave birth to her only child at age 32. She has no family history of breast or ovarian cancer.

On physical examination, a 2-cm, hard, irregular, fixed mass is palpated in the lower outer quadrant of the right breast, with slight overlying skin dimpling and a 1.5-cm hard mass in the right axilla. Core-needle biopsy of the mass shows ductal carcinoma; fine-needle aspiration cytology of axillary nodes shows adenocarcinoma.

Which of the following is the best next step in management?
a. Lumpectomy and sentinel node biopsy
b. Chemotherapy
c. Modified radical mastectomy
d. Endocrine therapy
e. Radiation therapy

Chemotherapy

This patient has a T3N1M0 Stage IIIB or locally advanced breast cancer which is best treated with multimodal therapy and usually chemotherapy is administered first (i.e. neoadjuvant chemotherapy).1 The mass is fixed to the chest wall so radical surgery would be required if an operation were performed first. Administration of chemotherapy in a neoadjuvant (i.e. before surgery) fashion may shrink the tumor and may it mobile in relationship to the chest wall and thereby permit a less radical operation.

A previously healthy 48-year-old woman (gravida 3, para 2) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 12. She gave birth to her first child at age 22. Her father's sister had breast cancer diagnosed at age 35.

On physical examination, a 1-cm, hard, irregular mass is palpated in the outer lower quadrant of the right breast. There is no skin retraction or axillary lymphadenopathy. Core needle biopsy is performed, showing infiltrating ductal carcinoma, HER2/neu negative and estrogen and progesterone receptor positive.

Which of the following is the best next step in management?
a. Simple mastectomy
b. Endocrine therapy
c. Radiation therapy
d. Chemotherapy
e. Lumpectomy and sentinel node biopsy

Lumpectomy and sentinel node biopsy

Imaging for Abdominal aortic aneurysm

CT and angiography- most accurate
Xray
Ultrasound
Angiography

A 66-year-old man is referred for evaluation of painless left axillary adenopathy. The patient is a dairy farmer who spends most days working outside, and he has a history of recurrent sunburns. He has hypertension that is well controlled with an angiotensin-converting enzyme inhibitor.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 76/min, respirations are 14/min, and blood pressure is 124/76 mm Hg. A complete skin examination reveals signs of chronic sun damage but no discrete suspicious lesion. Cytologic evaluation of an axillary lymph node biopsy is consistent with metastatic melanoma.

Laboratory studies show a normal serum lactate dehydrogenase level. A radiologic evaluation of the lesion shows no evidence of a primary tumor or distant metastatic disease.

Which of the following is best next step in management?

A. Observation only
B. Palliative axillary radiation
C. Left axillary lymphadenectomy
D. Systemic temozolomide
E. Sentinel lymph node biopsy

Left axillary lymphadenectomy

A 34-year-old woman with a family history of melanoma consults her physician regarding the possibility of undergoing genetic testing for the disease. She reports that she uses sunscreen faithfully whenever she is outdoors but is concerned about her risk for skin cancer because she frequented tanning salons while she was in college. Her physician explains that patients with a family history of melanoma who are found to carry the melanoma susceptibility gene may also be at increased risk for which of the following?

A. Papillary thyroid cancer
B. B-cell lymphoma
C. GIST tumors
D. Pancreatic cancer
E. Tumors of the upper aerodigestive tract

Pancreatic cancer

A previously healthy 36-year-old woman is evaluated for a lesion on the top edge of her left ear that she first noticed 6 months ago. The lesion itches and sometimes bleeds with scratching. The patient reports using several types of over-the-counter body lotions and hydrocortisone creams without relief. She has fair skin and admits to unprotected sun exposure and frequenting tanning salons.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 72/min, respirations are 18/min, and blood pressure is 120/74 mm Hg. Examination shows a 1.5-cm flat, nonpigmented, waxy lesion on the helix of the left ear; obvious excoriation is apparent.

Which of the following is the most appropriate next step in management?

A. Detailed head and neck examination followed by biopsy
B. Immediate biopsy
C. Full dermatologic examination followed by immediate wide excision
D. Full dermatologic examination followed by biopsy
E. Full dermatologic examination and initiation of antibiotic therapy

Full dermatologic examination followed by biopsy

A 65-year-old man comes to the emergency department because of vomiting, increasingly severe cramping abdominal pain, and distention for the past 12 hours. He had no history of previous abdominal surgery. Two years ago, he underwent surgical excision of a 1.5-cm tubular melanoma on his back. He takes no medications.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 74/min, respirations are 16/min, and blood pressure is 122/70 mm Hg. The abdomen is distended with high-pitched tinkling bowel sounds. There is significant tenderness to palpation.

Plain radiographs of the abdomen show multiple air-fluid levels with several distended loops of small bowel.

Which of the following is the best next step in management?

A. Exploratory laparotomy
B. Analgesia and observation only
C. Positron emission tomography
D. Abdominal ultrasound
E. Computed tomography of the abdomen

E. Computed tomography of the abdomen

A 54-year-old man returns to your office for follow-up 1 week after biopsy of a suspicious pigmented lesion on his right cheek. Pathologic evaluation confirmed a superficial spreading melanoma reaching a maximum depth of 4.2 mm. With the exception of the lesion, the patient is in otherwise good health.

Physical examination shows no additional abnormal dermatologic or nodal basin findings.

Which of the following is the best next step in management?

A. Positron-emission tomography
B. Magnetic resonance imaging of the brain
C. Computed tomography of the chest
D. Magnetic resonance imaging of the head and neck
E. Computed tomography of the abdomen and pelvis

Positron-emission tomography

A previously healthy 47-year-old woman is referred for evaluation of a suspicious mole noticed by her primary care physician during a regular physical examination. Because of the mole's location on the back of the patient's right shoulder, she is unsure whether it has changed in size or appearance. She has fair skin and admits that she frequently sunbathed without protective sunscreen during her teens and twenties.

On physical examination, temperature is 98.6°F (37.0°C), pulse is 74/min, respirations are 16/min, and blood pressure is 122/70 mm Hg Dermatologic examination shows a lesion measuring 4 mm in diameter with slightly irregular edges; the color of the mole varies from light tan on one side to black on the other. A full-thickness excisional biopsy is performed, and pathologic report confirms the presence of atypical, immature melanocytes extending into the dermis; Breslow thickness is 1.5 mm.

Which of the following is the best next step in management

A. Computed tomography of the chest
B. Sentinel lymph node biopsy
C. Positron-emission tomgraphy
D. Serum melanoma markers
E. Magnetic resonance imaging of the brain

Computed tomography of the chest

A 45-year-old man is evaluated because his wife is concerned that a mole on his left shoulder blade has recently changed in color. The patient has pale skin and has experienced multiple sunburns during his lifetime. Four years ago, he received treatment for basal cell carcinoma.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 68/min, respirations are 16/min, and blood pressure is 122/70 mm Hg. Dermatologic examination shows a 1-cm asymmetrical lesion on the left scapula. The lesion is darkly pigmented with at least three shades of color.

Which of the following biopsy techniques is most appropriate?

A. Punch biopsy at the margin of the mole
B. Punch biopsy in the darkest part of the mole
C. Excisional full-thickness biopsy
D. Incisional full-thickness biopsy
E. Shave biopsy

C. Excisional full-thickness biopsy

Since the lesion is small ( 1cm) and present in a location that allows for complete removal ( back/trunk), the best biopsy would be an excisional biopsy.

68-year-old woman comes to the physician for a new patient visit. Six months ago, she underwent successful surgical treatment for basal cell carcinoma. She has no chronic health conditions, and she takes no medications.

On physical examination, her temperature is 98.6°F (37.0°C), pulse is 70/min and regular, respirations are 14/min, and blood pressure is 140/68 mm Hg. The excision site shows a well-healed scar, and no new lesions are apparent. The remainder of the physical examination, including dermatologic examination, shows no abnormalities.

Which of the following is the most appropriate management approach for this patient?

A. Annual dermatologic examination to evaluate for local recurrence
B. Annual liver function testing
C. Sun awareness education and annual full dermatologic exam
D. Regular annual age-appropriate physical examination
E. Annual chest radiograph

Sun awareness education and annual full dermatologic exam

A 49-year-old man returns for a 5-year follow-up examination after successful treatment of a nodular-type melanoma on his back. The lesion was 4.2 mm in thickness, and wide local excision and sentinel lymph node biopsy were performed. He underwent subsequent involved lymphatic basin excision and postoperative chemotherapy. He reports that he now feels well with the exception of headaches occurring 2 to 3 times weekly. He has been very vigilant with skin self-examination.

On physical examination, his temperature is 98.6°F (37.0°C), pulse is 72/min and regular, respirations are 16/min, and blood pressure is 124/68 mm Hg. A full dermatologic examination shows no evidence of any local or regional recurrence or any new lesions. Neurologic examination shows no abnormalities.

Which of the following is the best next step in management?

A. Positron-emission tomography
B. Schedule a follow-up examination in 2 years
C. Schedule a follow-up examination in 1 year
D. Computed tomography of the chest
E. Magnetic resonance imaging of the brain

Magnetic resonance imaging of the brain.

Headaches presenting in patients with a history of melanoma need to be further workup to role out brain metastasis.

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